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Food and weight in the age of Ozempic

 November 29, 2023 at 12:21 PM PST

S1: Welcome in San Diego , it's Jade Hindman. Obesity is on the rise. So we'll talk about ways to reverse the trend and do it safely , plus ways to eat more mindfully. This is Midday Edition , connecting our communities through conversation. For many of us , the holidays and food go hand in hand and eating is at the center of how many of us celebrate. But this holiday season , recent weight loss treatments like Maduro , wig and Ozempic have reshaped many people's relationship with food. These medications target the hormones that generate hunger and have gotten a lot of attention as a way to lose significant amounts of weight. Dr. Mark dobro is the director of obesity medicine at sharp Reed Steely Medical Group in San Diego. He spoke with midday producer Andrew Bracken about the limits of the popular drugs. Here's that interview.

S2: So do you feel that these drugs. We've heard so much about them over the past year or so. Ozempic we go v magro.

S3: I think they're they're getting quite a bit of hype right now. And , you know , we're always looking for that magic bullet. And I think this may be the closest thing to it. Although these medications certainly do have , you know , quite serious side effects and not all patients can tolerate. And I think there's a perception out there that this is the magic bullet and there's no problems associated with its use. And , you know , patients are looking to get their hands on these. But I think in practice , we do see that this is just another tool in our arsenal and that we have to use it with the appropriate patient.

S2: And taking us back a little bit. I mean , the origin of these medications largely wasn't about , you know , weight loss specifically , but it was more about treating diabetes. Is that is that fair to say ? Yes.

S3: That's correct. These drugs actually go back , you know , in some cases decades to the treatment of diabetes and some of the , the , you know , the diabetic versions are still available , but some of them are just not as potent with weight loss. And some of our newer medications , for example , Ozempic would go by and now Zep bound , these are more powerful and they tend to work in the same fashion , although they have more effect with appetite suppression and weight loss.

S2: And you mentioned Zep bound there. I've heard about a couple of the other ones , but Zep Bound is a more recent version of these.

S3: Appetite is actual molecule , and it's been used for quite some time for diabetes in the form of mango. And the Zep bound is the newly approved with the new indication we have for weight loss. The new brand name for the weight loss version.

S2: And so taking this back , I mean , how big of a problem is obesity in America today ? Can you tell us about the scope of that problem ? Sure.

S3: I mean , I think most , most people are aware that this is a major issue and that up to 40% of adults in the United States who are , you know , are going to fit into the category of overweight or obese. So we're looking at a problem that just continues to become bigger over time. And we need tools. We need to have options on the medical side , on the pharmaceutical side to assist patients.

S2: And so , you know , how have these medications changed the suite of treatment options for your patients ? Yeah.

S3: Well we've always had a good arsenal of medications. There's some good oral medications for example , as a medication I've used for the past 12 years that's been around and been a very good medication to help our patients. But now we have these other newer generation injectables that are very sought after , and they do tend to be on the more potent side , although as I mentioned previously , the side effect profile can be inhibitory.

S2: And these drugs are not cheap at all. I think some of them , they can run into thousands of dollars per month.

S3: And the availability has been an issue just because of the high demand. And , you know , there's been nationwide shortages of all these newer injectables. Yeah , even the the diabetic versions patients have had difficulty obtaining as far as the cost , I think , you know , there's a lot of cost pressure , so to speak. These drugs will have to come down and cost over time. They're just not reasonable at their current retail prices , which are over $1,000 a month. If you look at a disease with obesity , with such a high prevalence , and so many patients could potentially take this medication , and the cost per year is astounding. So right now , insurance companies , some are covering , some are not. It's some it depends upon the plan. And of course , once we start a patient on medication we want to see response. And that response is typically seeing about 5% weight loss over time to ensure that the patient is responding. And if they are , then most of these medications are indicated for long term use. I think once you start them , any treatment , the oral medications , the injectables you should just plan on taking long term. There's there's an issue of what we call the step point with our weight. And it's basically something that happens with our with our the feedback in our brain , the hormonal adaptation that occurs that will push us back up in weight if we don't continuously take something that will bring us down. And good , a good way to think about this is that our brains are turned on at baseline to eat , and we only get satiety and fullness after we eat , because hormones are then hitting those areas of the brain telling us that we're full , well , those hormones are going to fade out over time , and then you're going to be hungry again because that's your baseline. Well , these newer medications are hormonally driven , and they do affect areas of the brain which can induce satiety. And that the newer injectables , for example , once you inject you're going to get effect for about a week. So the medicine is continually telling your brain that essentially food is available and that suppresses the hunger or increases satiety. And so the problem being there is that once you take away the medication , whether it's oral or injectable , your brain is going to reset , the hunger will come back , the satiety will wane , and then you'll be back to where you were. So we do understand that now that long term treatment is the way to go with these medications.

S2: What do we know about what happens if a patient goes off these , you know , after losing weight ? Do they , you know , regain that weight. What do we know there. Yeah.

S3: Well that that was one of the studies that was done with some that looked at initiating patients on medication , titrating them up to the full dose , which took five months , and then withdrawing the medication. And when the medication was withdrawn , you could see the curve of the patients regaining weight over time. And it looked like if you extrapolated that curve over a longer period of time , they were going to get right back to where they started. And in that study , you know , half the patients were withdrawn. The other half stayed on medication. The ones who continued on medication continued to go down and stabilize at the lower level. So this is very common. We do see this in clinical practice that once we lift our treatment , the the hunger does return and the weight does rebound.

S2: And with all that in mind , I mean , can you talk a little bit about who should consider these medicines versus other types of weight loss treatments you make ? The point is , there's a lot of different options , you know , to tackle this issue.

S3: And if we look at the FDA criteria , any patient who's overweight with a BMI of 27 or greater , who has a comorbidity , something that's related to obesity , for example , let's say elevated cholesterol , there a candidate or any patient with a BMI of 30 or greater with or without a comorbidity. So as you can see , this includes a large number of patients overweight into the obese category. And so think which patients would would I avoid giving these medications to likely someone who has significant gastrointestinal issues that , you know , they may be intolerable. Certainly the boxed warnings on the package for the GLP one drugs indicates we should avoid in patients who have a family history of medullary thyroid cancer. But think in general , you know , a lot of these patients , a lot of patients can can take these medications. And then we can see what the response is and determine if we have a , you know , a side effect profile that's tolerable.

S2: And for patients who these medications may. May not work for. Can you talk about some of the other treatments that are effective or things that you work with with your patients ? Yeah.

S3: Well , we have , as I mentioned , basically an arsenal of proven drugs that we've had for over a decade that that I've been using successfully with patients. I would say , you know , Simeon , contrary , for the two newer generation drugs that have been around for over a decade , and for example , Kissinger's a combination of Benjamin and Topiramate been around for about 12 years , and it's taken once a day and does not tend to have any gastrointestinal issues. So that might be more appropriate in someone who has a more sensitive stomach. But think what happens when we have the GLP one. See , you know , montero's out there is that it actually creates more interest and more awareness of the condition and the fact that we do have these , you know , you know , pharmaceutical options available to treat patients. So think prior , I mean , I think there was a kind of an issue where patients didn't understand that we did have these tools. And now I think they're becoming more aware. And it does open up the door for us to try. You know , any of the tools are Arsenal to be able to help with this condition.

S2: In conversations about weight , I think we hear a lot about willpower.

S3: And we we've known for a while that willpower doesn't have much of an effect on your desire to eat. Most of the desire to eat is occurring centrally through chemical changes in the brain that are driving us to eat. It's it's hormonal in nature , it's biologic in nature , and all that does is create a sense of failure in the patient to talk about willpower. There's such a strong mechanism that's been that's evolved over the years to allow us to maintain our body weight , that to try and assume that using willpower to overcome this biological mechanism is valid is not it's not real. So think that in general , willpower should not be in any part of this conversation. I think skill power may be the skill to know what to do , and I think once you assist patients with satiety and appetite suppression with these medications , it's very apparent that willpower has no role here , that if someone is not hungry , they're not going to eat. And the converse is true if someone's hungry , they're going to eat. So I think all willpower does is create a sense of guilt that that we don't need in this issue.


S3: And , you know , we've we've tried just died and exercise alone , you know , forever. And it's not resulted in the country getting healthier. And weight's dropping. It just hasn't it's been an abject failure. Now that's not to say that you don't need diet and exercise. They're very important adjuncts to what we do. And without them , I don't think you can be fully healthy. An example would be , you know , on on some of these newer medications , you're going to lose a significant amount of weight. But I think the perception is when you lose weight , you're losing just body fat. And that's not the case. You lose muscle and bone as you lose weight. As a matter of fact , about 25% of your body weight that's dropped is going to be muscle and bone. It's going to be lean tissue. So what we do need to encourage is patients to exercise , especially while they're losing weight. And resistance training becomes very important , having sufficient protein intake and lifting weights to preserve that lean muscle mass. But I think the key point is you have to do it all. You have to you have to be exercised and you have to have those correct behaviors. And then the assistance of the medication to help with the appetite.

S2: And you say there are two reasons , ultimately why we overeat.

S3: And these desires are coming from different parts of the brain in the posterior part of the brain , the dorsal complex. That's where a lot of our cravings come from. And we also have the prefrontal cortex , where a lot of the emotional eating comes from. And then the hypothalamic area where our our main control mechanism for hunger exists. And so I think it's important when at least when I'm looking at a patient trying to determine whether they're , they're overeating due to cravings or true hunger , and then maybe tailor a medication to that. It's a big problem , and some of the medications are better at one than the other. A lot of them work for both , but you really want to make sure that you're selecting the patient appropriately for what their major condition is , whether it's a craving issue , emotional eating , or whether it's two really just straight hunger base.

S2: So , you know , last week was Thanksgiving. I think a lot of us , myself included , associate the holiday season with food. You know , we might eat more , eat more socially. You know , it's just part of how we celebrate. I'm just curious if you have any thoughts of how these medications have impacted your patient's relationship to food. And , you know , in times like these when food is kind of at the center of our culture.

S3: Yeah , I think in a major way , I think and I think a lot of the retailers selling through them notices , too , is that with more patients using these medications , they're just not eating as much that they shifted what they're eating , the volume , the proportions are down. And that's that's we're seeing that through that through the , you know , the grocery grocery stores. And like I said , when you're sitting at the table for Thanksgiving and if you don't have that strong hunger drive or you're getting full very easily , which is what happens with these medications , you're you're not going to take more than a few bites and starting to feel that fullness. So you're certainly going to eat less. And I think , you know , when I look at holidays , I mean , you know , we basically have a major holiday almost every month. And , you know , if you if you overate with every one of those holidays , you're going to have a problem every year and think with these medications , you can be more mindful of what you're doing. You can think about what you're doing because you're not going to have that strong hunger drive. You're going to be full a lot easier. So it it does take some of that pleasure maybe out of the holidays if the pleasure was , you know , sitting around consuming , you know , large amounts of food and think that , you know , that that part of the holidays is probably not the important part. Mean , for example , with Thanksgiving , we're there to give thanks. We're not there to to gorge and and think. We do lose track of the holidays. And I've , I've always said this to patients. A lot of our holidays have been converted to food holidays. You know , we all we think about is what the food is with the holiday. We forget about what what we're celebrating. So I think in general it just makes patients more mindful.


S3: We're we're dealing with , you know , food manufacturers who figured out how to , you know , get us addicted to food. Um , you know , by the addition of salt , fat and sugar at certain levels to make foods very addictive. And so our environment is very poor. And , you know , we've we've always talked about the genetic basis of obesity. And , you know , how it's with obesity increasing to such high rates. Now we know that our genes haven't changed over the past 50 years yet. The the number of patients who struggle with overweight and obesity is has skyrocketed. Well , how do you explain this ? You explained it through our environment. Our environment is very toxic. Are the food that we have is very adulterated. It's designed to be addictive. It's very non nutritious. And then of course our our environment is one where we're sedentary. We're on our phones and our computers , we're watching TV so we're not moving. We're eating what I would call toxic food and a very poor environment. So , you know , think of the medications as a way to maybe kind of even the playing field a little bit , where , you know , the addictive nature of food may not be that when you're on medication.

S1: That was Mark Jabra speaking with midday producer Andrew Bracken. Have you encountered the limits of these new weight loss drugs ? Give us a call at (619) 452-0228. Leave a message or you can email us at midday at Coming up , the conversation continues as we speak to a nutritionist about creating healthier habits.

S4: We need to go back to a time where food was not so convenient and not so ubiquitous in our lives.

S1: That's next on Kpbs Midday Edition. Welcome back to Midday Edition , I'm Jade Hindman. Obesity has seen major increases over the past several decades. According to the CDC , more than a third of Americans struggle with obesity. As we just heard , one reason for this is our food environment. The reasons behind why we eat have changed over the years. Food is more accessible today than in years past. You can find it at any time of the day and night , but that doesn't make it healthier. Here to talk more about food and our relationship to it is Tracy Roberts. She is a clinical dietitian with UC San Diego Health. Traci , welcome to Midday Edition.

S4: Thank you so much for having me. I'm very happy to be here.

S1: So glad to have you. So we just heard from obesity specialist Dr. Mark gabbro , and we ended that conversation hearing about his thoughts on our food environment and how much of it is out of our control.

S4: As you mentioned in the intro , we have accessibility to food 24 over seven. We can get food even delivered to our home almost any time of the day or night. However , I don't agree that it is entirely beyond our control. I believe that we can still make good choices. I believe that maybe the most effective way to change our food culture is in voting with our dollar. So I do believe that we have some capacity for influence and for change in our current food environment.


S4: I think if we are to look forward and strive towards better health , better relationship with our food , better relationship with our bodies , we need to go back to a time where food was not so convenient and not so ubiquitous in our lives. We need to actually put a little bit more intention and effort and energy into the foods that we select , how we prepare those foods , and even how we eat those foods. I think that's really the key. And starting to kind of turn around. I hate to use the word toxic , but to to turn around the unfavorable food conditions that we have right now.


S4: Most of my patients , they want to eat more healthy. They want to cook better foods for themselves and for their families. They just really struggle with finding time to grocery shop , finding time to prepare a meal. It's much easier to order takeout or to go through the drive thru. So I think finding some time for eating or for cooking for shopping is really the main barrier for most people.

S1: Well , and earlier I mentioned that the reasons for why we eat have really changed over the years.

S4: We use food for many different ways celebrations , coping , stress , boredom. We eat for many , many more reasons beyond just hunger and beyond nutrition. And I think again , given the current pace of life , how busy everyone is , the multiple stressors that we have. Food is seen now more as a as a task. And so we tend towards those foods that are convenient. Let's get the job done. It's time for dinner. Let's just get something that we can eat and be done with it and move on with our night. We don't have a lot of time. I'm going to eat my lunch while I'm working. I'm going to have a protein bar in the car while I drive to work. So I think those are some of the challenges that we're facing right now.

S1: And you touched on this earlier , but you say the issue of eating healthy is really not about education. Tell me more about that.

S4: I think most people would probably say , and again , this comes from a lot of the patients that I work with , I know I should eat healthier , I know I should have more fruits and vegetables , I don't hydrate enough. I don't think that knowledge really is the deficit. I believe some people are really just struggling with prioritization of food as a means for better health. Again , we we tend to focus a little bit now in our culture of what are the quick fixes. We're going to the internet for information about nutrition , and we're inundated with how we should be eating. Should we be vegan or vegetarian ? Should we be eating paleo ? Should we start keto ? Is intermittent fasting the way to go and more of our focus and attention is put into these hacks , these dietary hacks , rather than in the food itself. If we could shift our attention and our focus into the food itself , honestly , it would matter less. The pattern of our eating. Whether we're a vegetarian , you can be healthy. As a vegetarian , you can be healthy eating paleo. But the thing that's more important is are we putting time and effort into our food ? I think that's the path forward and really. Understanding the value of our relationship with food and putting some effort and some energy into that relationship versus finding the quote unquote right diet or the right way to eat. Right.

S1: Right.

S4: You know , we all have 24 hours in the day and we all have buckets that require our time and attention. And it does take a very conscious , deliberate choice to start to put more of your time and more of your energy into health and eating. Now , I think some people maybe they'll feel frustrated with where they perceive themselves now , where they would like to go with their diet , and it just seems insurmountable , especially if they are dealing with time issues or budgetary constraints. So it feels almost , you know , why should I try if I'm not going to hit this ideal ? I think really a good mindset is one more thing. One more night of cooking dinner , one more day of going to the market to grocery shop rather than going to the drive thru or ordering takeout. You don't have to hit that perfect mark. I always tell my children progress , not perfection. So if you can even incorporate , Thursday night's going to be the night that we all make dinner or even two nights a week. We're going to sit down as a family and enjoy a meal. No TV , no cell phones. We're just going to start small and start to incorporate some healthy habits and build from there.

S1: Finally , you know , the holidays are here and food can often play a big part in celebrating. It's such a social thing.

S4: It's a wonderful time for us to kind of retool our relationship with food. Of course , we're gathering with friends and with family. Food is a part of those celebrations , as it should be. It's integral to our celebration of the holidays. I think you'll find a lot of holiday parties. People are more apt to bake some cookies or , you know , make a soup or , you know , put together a dinner for friends and family. I think that's a great way. It's a gateway for us to move into the new year with that mindset of community eating , of the importance of sharing food with friends , of making some meals at home. Get your kids involved in the kitchen or cook a meal with your spouse. Having that more tacit relationship with food and with friends , I think can help set us up for the new year. I think where we run into trouble with the holidays is we have the friends over for dinner or for a get together , and there's. A large amount of food , right ? We have some cookies and we make pies , and we have lots of desserts with our food. And that's after we've had appetizers and had our main meal. Again , I think intentionality and mindfulness is really the key. There have been plenty of studies on the enjoyment of food at any portion , and what the researchers found was your enjoyment , your pleasure that you get from any certain food , let's say cheesecake. That's my favorite. After the first 2 or 3 bites of cheesecake are enjoyment drops off precipitously. Those first few bites are very rewarding. And as we're into bite 610 , 12 , our enjoyment kind of lags. And so I don't ever want to discourage anyone from enjoying food. I think eating for pleasure and getting pleasure from the foods that you make and that you share with others is hugely important. However , just to keep in mind that we don't need a large portion to enjoy those different types of foods. So again , I would just be mindful of how much we're eating to not eat mindlessly , to really enjoy and appreciate our food and and keep a focus on when when that pleasure starts to drop off and we can head outside to play football with our friends.

S1: Traci Roberts is a clinical dietitian with UC San Diego Health. Tracy , thank you so much for joining us. Absolutely.

S4: Absolutely. Happy to be with you guys today. Thank you.

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A grocer is pictured in the produce section in this undated photo.

Obesity has seen significant increases over the past several decades in the United States. Obesity prevalence in the country increased by more than 10% between 1999 and 2020, according to the U.S. Centers for Disease Control.

In recent years, medications such as Wegovy, Mounjaro, and Ozempic have become popular tools in treating obesity, as well as Type 2 diabetes.

Meanwhile, the reasons why we eat have changed over the generations. Food has become more accessible and plentiful than in the past, but it may not be healthier.


Dr. Mark Jabro, director of obesity medicine, Sharp Rees-Stealy Medical Group

Traci Roberts, clinical dietician, UC San Diego Health